F500-149-000 Affidavit of Experience for Washington Electrical Trainees 12-2020 GL 1355 Index: AFFT
Affidavit of Experience for
Washington Electrical Trainees
Trainee Responsibilities:
Questions? 360-902-5269
Mail Affidavit and Fee* to: L&I Electrical Program
PO Box 44460
Olympia, WA 98504-4460
*Update Fee of $53.40 is required for each affidavit you submit
more than 30 days after your training certificate expires.
No fee required to submit earlier.
No fee required
to submit affidavits for hours worked while
registered in an approved electrical Apprenticeship program.
1. You must submit the original version of this form.
2. Do not lose credit for your hours submit affidavits on
time. You have 180 days from the date your training
certificate expires to submit affidavits for hours worked in the
24 months before that date.
Exception: Affidavits for hours worked while registered in an
approved electrical Apprenticeship program
may be
submitted any time.
Please print clearly in ink. Make no omissions, errors, or alterations. Trainee must submit the original copy to L&I.
Name of Apprenticeship Training Director or Electrical Administrator/Master Electrician or Employer’s Authorized Signer
attest and
Name of Apprenticeship or Employer
Apprenticeship WSATC ID # or Electrical Contractor License # or UBI #
certify that
Name of Washington L&I Electrical Trainee
Trainee’s L&I Training Certificate #
supervised in accordance with RCW 19.28 and WAC 296-46B from
(Claim no more than
24 months per affidavit)
while engaged in the electrical construction trade for the number hours in WAC 296-46B-920 categories below.
(75% supervision required)
(100% supervision required)
Commercial or Industrial
Domestic Well
HVAC/Refrigeration – Restricted
Pump and Irrigation
Non-Residential Lighting Maintenance
Residential Maintenance
Limited Energy System
Restricted Non-Residential Maintenance
Appliance Repair
Non-Residential Maintenance
Equipment Repair
Signature ― Sign below in the presence of a Notary Public
Door, Gate, and Similar Systems
I hereby certify that the information on this affidavit is true and accurate. I acknowledge that the department may issue
citations for false statements or material misrepresentation or other violations per RCW 19.28 and WAC 296-46B.
Signature of person named above - Apprenticeship Training Director, or Electrical Administrator/Master Electrician, or Employer’s Authorized Signer
Signed before me on
For L&I Use – Transaction ID and Date Stamp Field
Signature of Notary Public
Residing in
Notary Stamp or Seal below must be affixed in ink and be capable
of being photocopied. Electronic notarization accepted.